Get the Get the free EXHIBIT 1: INDIVIDUAL ENROLLMENT REQUEST FORM ...

OMB No. 09381378 Expires: 7/31/2023ENROLLMENT REQUEST FORM TO ENROLL IN ELIXIR PLUS (PDP) Who can use this form? People with Medicare who want to join a Medicare Prescription Drug Plan To join a plan,

How to fill out exhibit 1 individual enrollment

How to fill out exhibit 1 individual enrollment

1. To fill out Exhibit 1 Individual Enrollment, follow these steps:
2. Start by entering your personal information such as name, address, and contact details.
3. Provide your date of birth, social security number, and gender.
4. Specify the effective date of enrollment and the type of coverage you are applying for.
5. Include any dependents you wish to enroll, providing their names, dates of birth, and relationship to you.
6. Answer any additional questions or provide required documentation as requested.
7. Review the completed form for accuracy and sign and date it before submission.
8. Submit the filled-out Exhibit 1 Individual Enrollment by the designated method specified.
9. Keep a copy of the form for your records.

Who needs exhibit 1 individual enrollment?

1. Exhibit 1 Individual Enrollment is needed by individuals who are applying for enrollment in a specific health insurance plan.
2. It is typically required for those who want individual coverage rather than being part of a group plan.
3. Individuals who are not eligible for employer-based health insurance or government-sponsored programs may need to fill out Exhibit 1 for individual enrollment.

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